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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 548-550

Intravitreal triamcinolone in the treatment of serous retinal detachment secondary to choroidal osteoma without choroidal neovascularization: A case report


1 Department of Ophthalmology, Mackay Memorial Hospital, Taipei, Taiwan
2 Department of Ophthalmology, Mackay Memorial Hospital; Department of Optometry, Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan

Date of Submission14-Oct-2020
Date of Acceptance21-Feb-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. Shawn Tsai
Department of Ophthalmology, Mackay Memorial Hospital, No. 92, Section 2, Chun-Shan North Road, Taipei - 10449
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_3259_20

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  Abstract 


Choroidal osteoma (CO) is a rare, benign, ossifying tumor of the choroid usually seen in otherwise healthy eyes. Vision impairment in CO is mainly attributed to serous retinal detachment (SRD) with or without choroidal neovascularization (CNV) and subfoveal tumor decalcification. We report a 54-year-old man with CO-related SRD without concomitant CNV in his right eye. The subretinal fluid was refractory to intravitreal aflibercept injections. Intravitreal injections of triamcinolone acetonide (IVTA) were performed and resulted in significant fluid resolution and remarkable visual improvement. This is the first reported case in the literature demonstrating the efficacy of IVTA in CO-related SRD.

Keywords: Choroidal osteoma, intravitreal triamcinolone, serous retinal detachment


How to cite this article:
Chiu FY, Chen LJ, Chan WC, Tsai S. Intravitreal triamcinolone in the treatment of serous retinal detachment secondary to choroidal osteoma without choroidal neovascularization: A case report. Indian J Ophthalmol Case Rep 2021;1:548-50

How to cite this URL:
Chiu FY, Chen LJ, Chan WC, Tsai S. Intravitreal triamcinolone in the treatment of serous retinal detachment secondary to choroidal osteoma without choroidal neovascularization: A case report. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:548-50. Available from: https://www.ijoreports.in/text.asp?2021/1/3/548/320094



Choroidal osteoma (CO) is a rare, benign tumor composed of mature cancellous bone. It typically appears as a well-demarcated, slightly elevated, yellow-white lesion located in the juxtapapillary or macular area.[1],[2] Despite its benign nature, visual impairment in CO may result from either atrophy of photoreceptors and retinal pigment epithelium (RPE) overlying the subfoveal decalcified osteoma, serous retinal detachment (SRD), choroidal neovascularization (CNV), or hemorrhages.[2],[3]

Reported treatment strategies for SRD related to CO include observation, laser photocoagulation, photodynamic therapy (PDT), transpupillary thermal therapy (TTT), and intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents.[2],[4],[5],[6],[7]

Herein, we present a case with SRD secondary to CO without CNV, which was unresponsive to the anti-VEGF agent aflibercept. Significant fluid resolution and visual improvement were achieved with intravitreal triamcinolone acetonide injections (IVTA). This is the first reported case in the literature.


  Case Report Top


A 54-year-old otherwise healthy man presented with metamorphopsia and dim vision in the right eye for 2 months. His best-corrected visual acuity (BCVA) was 20/33 in the right eye and 20/20 in the left eye. Anterior segment examination was unremarkable in both eyes. Fundus examination of the right eye revealed a large, slightly elevated yellow-white lesion in the juxtapapillary area with well-demarcated borders and scattered pigment clumping sparing the fovea. No subretinal hemorrhage was observed [Figure 1]a. Ultrasonography showed a hyper-reflective choroidal mass with acoustic shadowing [Figure 1]b. Computed tomography disclosed a hyperdense plaque with bone density [Figure 1]c. The diagnosis of choroidal osteoma (CO) was made. Fluorescein angiography showed early spotted hyperfluorescence with late staining [Figure 1]d and [Figure 1]e. Optical coherence tomography (OCT) obtained with Cirrus HD-OCT 4000 (Carl Zeiss Meditec) demonstrated subfoveal serous retinal detachment (SRD) with a central macular thickness (CMT) of 430 μm [Figure 2]a. There was no evidence of choroidal neovascularization (CNV) during the investigation.
Figure 1: (a) Fundus photography of the right eye showed a well-defined yellow-white elevated lesion in the juxtapapillary region. (b) Ultrasound B-scan showed a hyperreflective mass with acoustic shadowing. (c) Computed tomography disclosed a hyperdense plaque with bone density. (d and e) Fundus fluorescein angiography revealed early patchy hyperfluorescence and late staining. Disc telangiectasia with late dye staining was also noted. No choroidal neovascularization was identified

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Figure 2: Optical Coherence Tomography (OCT) images of the right eye. (a) Baseline OCT showed serous retinal detachment and mild epiretinal membrane nasal to the macula. (b) The subretinal fluid (SRF) was refractory to 3 monthly intravitreal aflibercept injections. (c) OCT showed remarkable resolution of SRF 1 month after the first intravitreal triamcinolone acetonide (IVTA) injection. (d and e) Reaccumulation of subfoveal fluid was noted 2 months post-injection; repeated IVTA resulted in fluid resolution. (f) 22 months after the last IVTA, OCT showed mild retained fluid without foveal detachment

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The patient was given three consecutive monthly intravitreal injections of 2 mg of aflibercept. Subretinal fluid persisted and BCVA remained 20/33 the right eye [Figure 2]b. Intravitreal injection of 2 mg of triamcinolone acetonide (IVTA) was then performed. One-month post-injection, his BCVA in the right eye improved to 20/20 and OCT revealed dramatic fluid resolution with normal foveal contour [Figure 2]c. Reaccumulation of subretinal fluid was noted during follow-up at 2 months post-injection and repeated IVTA induced resolution of the fluid [Figure 2]d and [Figure 2]e. Five additional IVTA were performed over a 14-month period for the subfoveal fluid and showed favorable results. The patient developed cataract in his right eye one year after the first IVTA and received uneventful extracapsular cataract extraction with good vision recovery to 20/20. Minimal fluid without subfoveal involvement persisted, but the BCVA remained at 20/20 and no further intervention was warranted over a 22 months period of follow-up after the final injection. The CMT was 262 μm [Figure 2]f. The serial OCT images during the treatment and follow-up period were obtained with the Spectralis OCT (Heidelberg Engineering).


  Discussion Top


Choroidal osteoma is a rare benign tumor that tends to occur unilaterally in juxtapapillary or macular areas in young women.[1] Serous retinal detachment is one of the main causes of visual impairment in CO and occurs frequently in the absence of CNV.[5] Aylward et al. reported that 17 of 22 patients with CO-related SRD presented without CNV, and 4 of 17 patients end with visual acuity 20/200 or worse.[8]

The best treatment strategy for CO-related SRD with and without CNV is still under debate. Proposed treatments such as laser photocoagulation, PDT, or TTT showed variable results and can pose the risk of profound visual loss due to retinal damage, subsequent CNV development and subfoveal decalcification.[5],[7] Intravitreal injections of anti-VEGF agents including bevacizumab, ranibizumab and aflibercept were recently reported to have promising results.[2],[4],[5],[6] The favorable effects of anti-VEGF agents could be attributed to the antiangiogenic effect and decrease in vascular permeability of choroidal vessels.[5],[6] However, since nonresponder was still reported,[9] an approach utilizing solely in the antiangiogenic pathway may be insufficient for cases without CNV.

In the present case, the SRD was refractory to intravitreal aflibercept injections. Laser photocoagulation, PDT, and TTT were not performed due to lack of focal leaking points, large tumor size, and possible irreversible sequelae. Dramatic anatomical and visual improvement were achieved 1 month after a single IVTA. Recurrent fluid that occurred subsequently also responded favorably to repeated IVTA.

The exact pathogenesis of subretinal fluid in CO not related to CNV has not been elucidated. Previous report has proposed that CO could cause atrophy of the overlying RPE and Bruch membrane and therefore decrease the capacity of subretinal fluid removal due to alterations in fluid homeostasis across the outer blood-retinal barrier (BRB).[5] Triamcinolone acetonide, a corticosteroid suspension, has been shown experimentally to reduce breakdown of the BRB[10] and decrease vascular permeability of the choroidal vessels. These mechanisms form the rationale for corticosteroid treatment in CO-related SRD.

Glaucoma and cataract are the major ocular side effects attributed to corticosteroids. In the present case, no adverse reaction developed other than cataract formation, which was managed smoothly with good vision recovery. His IOP remained within normal limits during the postoperative follow-up period without any significant fluctuation in every visit. The occurrence of persistent fluid could be explained by RPE decompensation and peripapillary tumor compression which causes outflow obstruction of choroidal vessels and alters the peripapillary vascular circulation.

To the best of our knowledge, this is the first case reported in the literature to manage CO-related SRD with IVTA. The promising results indicate that IVTA could be an effective alternative therapeutic choice to improve both visual and anatomic outcomes in this group of patients. Follow-up for more extended periods of time is necessary to monitor the fluids, possible tumor growth or decalcification, and the development of CNV.


  Conclusion Top


Intravitreal triamcinolone acetonide injection is a feasible and potentially effective treatment option for patients with serous retinal detachment secondary to choroidal osteoma without choroidal neovascularization.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Shields CL, Shields JA, Augsburger JJ. Choroidal osteoma. Surv Ophthalmol 1988;33:17-27.  Back to cited text no. 1
    
2.
Alameddine RM, Mansour AM, Kahtani E. Review of choroidal osteomas. Middle East Afr J Ophthalmol 2014;21:244-50.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Shields CL, Sun H, Demirci H, Shields JA. Factors predictive of tumor growth, tumor decalcification, choroidal neovascularization, and visual outcome in 74 eyes with choroidal osteoma. Arch Ophthalmol 2005;123:1658-66.  Back to cited text no. 3
    
4.
Saitta A, Nicolai M, Neri P, Reibaldi M, Giovannini A, Mariotti C. Rescue therapy with intravitreal aflibercept for choroidal neovascularization secondary to choroidal osteoma non-responder to intravitreal bevacizumab and ranibizumab. Int Ophthalmol 2015;35:441-4.  Back to cited text no. 4
    
5.
Song JH, Bae JH, Rho MI, Lee SC. Intravitreal bevacizumab in the management of subretinal fluid associated with choroidal osteoma. Retina 2010;30:945-51.  Back to cited text no. 5
    
6.
Najafabadi FF, Hendimarjan SM, Zarrin Y, Najafabadi MF. Intravitreal bevacizumab for management of choroidal osteoma without choroidal neovascularization. J Ophthalmic Vis Res 2015;10:484-6.  Back to cited text no. 6
[PUBMED]  [Full text]  
7.
Browning DJ. Choroidal osteoma: Observations from a community setting. Ophthalmology 2003;110:1327-34.  Back to cited text no. 7
    
8.
Aylward GW, Chang TS, Pautler SE, Gass JD. A long-term follow-up of choroidal osteoma. Arch Ophthalmol 1998;116:1337-41.  Back to cited text no. 8
    
9.
Narang S, Sindhu M, Sheoran K, Kaur R. Choroidal osteoma: The varied response of subretinal fluid to anti-VEGF agents. BMJ Case Rep 2020;13:e234357.  Back to cited text no. 9
    
10.
Wilson CA, Berkowitz BA, Sato Y, Ando N, Handa JT, de Juan E Jr. Treatment with intravitreal steroid reduces blood-retinal barrier breakdown due to retinal photocoagulation. Arch Ophthalmol 1992;110:1155-9.  Back to cited text no. 10
    


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